Oral Medicine Medical History Documentation – A 2-cycle Audit

484 - Oral Medicine Medical History Documentation – A 2-cycle Audit

P Atkin M Simms
Presented by: Rachel Botrugno
Cardiff Dental Hospital

Introduction The Faculty of General Dental Practice ‘Clinical Examination and Record-Keeping Good Practice Guidelines’ state that a patient’s medical history (MH) must be documented and updated as necessary. This part of record keeping is considered a basic requirement of the clinical notes. Having an accurate and up-to-date MH is crucial and it can aid differential diagnoses, allow safe prescribing as well as appropriate management of medical emergencies. Methods First cycle: Data was collected retrospectively from the clinical notes of 60 consecutive patients attending the Oral Medicine clinic in December 2019. The following was recorded: 1. The grade of the clinician 2. Documentation of taking/updating the MH within the continuation sheet (Yes/No) 3. If the clinician had signed, printed and dated correctly on the dedicated MH form (Yes fully/ Yes partially/ No) 4. If the handwritten drugs listed on the MH form were legible (Yes / No/ Not applicable) 5. If a drug was prescribed during this appointment, including repeat prescriptions (Yes/ No) Results Within the first cycle, 40 patients were seen by undergraduates, 10 by dental core trainees, 7 by registrars, 3 by consultants. 53% of all staff completed the MH form documentation completely and 77% commented on the MH in the continuation sheet. This data was further analysed based on the grade of the clinician. In the MH forms that displayed handwritten drugs, 67% were considered legible. When a drug was prescribed, 29% of records matched all the desirable criteria as mentioned above (points 2,3,4). A second audit cycle was commenced and data collected prospectively in February 2021. Second-cycle results will show any improvement following staff education of the first-cycle results. Conclusion These findings highlighted scope for improvement in MH documentation. Changes implemented included writing the drugs list in capital letters to try and improve legibility and ensuring generic medications names are given.
Consent Statement: There are no details on individual patients reported within the abstract.

Poster
Poster Oral Medicine Medical History Documentation – A 2-cycle Audit

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